Why is my Mother (90) being denied skilled nursing? - AgingCare.com

Why is my Mother (90) being denied skilled nursing?

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My wonderful 90 year old mother had a hip replacement 16 days ago. On the 3rd day she was transferred into the hospitals acute rehab unit. She had a very difficult first week with severe pain. She is doing better now but is very weak and frail. We want her to be discharged to a skilled nursing facility to get more therapy and for her to regain her strength before she is discharged home. The skilled nursing facility told me that she has the medicare part A benefits for skilled nursing. When I told her rehab doctor that I wanted her to be discharged to a skilled nursing facility he blew up at me and said she cannot go there. He then said that if he knew that she wanted to go there he would never had admitted her to the acute rehab unit. I told him that this was not a plan. I had hoped that my mother would have recovered quicker but she did not. Anyway he refuses to discharge her to the skilled nursing unit, she is being discharged to her home on Fri. Her time in rehab has been 14 days. Can someone please explain to me what is going on. I was in tears when this doctor yelled at me. There must be some financial reason why he won't discharge my mom to skilled nursing, that I am unaware of.

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Army, you make a very good point. I think one of the issues as well would be where she'll get the most therapy. Social interaction is another issue; with one exception, my experience is that the therapy is generally better in a SNF but the medical care is obviously more expansive in a hospital.

SNFs can have offer pet and music therapy but a hospital can offer better support. Sometimes it's "6 of one, 1/2 dozen of the other".
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Perhaps the hospital's acute rehab can offer more help than a nursing home rehab. Me personally would rather utilize a hospital rehab center than a nursing home setting.
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Find out if the hospital is owned by a for profit entity. If so, it may be an issue of who gets the Medicare funding - the hospital's acute rehab unit or a SNF.

The for profit acquisitions in Michigan are making quite a difference in how hospitals here are being managed. There were some short term bad experiences but there are also some very significant long term results.

It may be that in the particular hospital your mother is in, each different unit is a profit center unto itself, and the doctor's participation is helpful to meet any profit goals.

I was surprised at what I learned when I dug into the issues surrounding the Accountable Care Organizations (ACOs). Now if I see a new physician I add to the intake paperwork that I won't agree to release of any information to these organizations.
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I think it may also have to do with some sort of rating system with medicare. Maybe he gets penalized by medicare if his patients don't progress in a linear fashion.
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Sunflower, there is a discharge department in mom's facility. Call them and ask for a layman's explanation of why mom can't go from acute rehab to subacute rehab at this time. The doctor may think that you want to admit your mom for long term care, rather than a second stop before home. It may have more to do with ego and his personal belief system than money, i,e, if you were "just going to put her in a nursing home"....
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Sunflower, I also don't understand why this doctor thinks that you would be able to predict the precise trajectory of your mother's recovery - after all, he didn't, did he?!

This man has been rude and unreasonable. Although concentrating on getting your mother the right kind of care for her is the only thing that matters, he owes you an apology for his rudeness and a clear explanation of his objections to discharging her to the SNF. Calmly but firmly insist on both.
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Wow,
Thank you all for your support!! I have been so upset. Country mouse, she does need a referral and the rehab doctor refused to write one for her. He was so angry at me, I suspect there must be some sort of financial reason why he won't let her go. I don't understand why he told me that if he had known from the beginning that she wanted to go to skilled nursing that he would never have accepted her in acute rehab. When my mom first had this operation I thought she would be home in a week. Everyone told me that the minimally invasive surgery had a quick recovery. I never even thought about skilled nursing before she had the surgery.

Garden artist, she will have outpatient scripts for rehab.

Geewiz thank you, medicare answered the phone and they referred me to an organization in the state where my mom is that may be able to help. They also told me that they cannot understand why she cannot be discharged to a Skilled Nursing Facility.
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Sunflower, forgive me for my unfamiliarity with the discharge system, but can you find out from the SNF whether a referral from your mother's rehab doctor is required for her to be admitted to the SNF? Because if not, I'd have thought it was between Medicare and your mother where she gets discharged to: I'm not clear how this decision rests with the disagreeable bullying doctor. Did you catch him on a bad day or something? Unforgivable, yelling at an anxious relative like that. Don't let it deflect you from getting what you feel your mother needs.

I'm sorry that your mother isn't making faster progress, but I would add that as long as she is now mobilised - getting out of bed, walking short distances with a frame? - it is still early days. Hip replacements get done at the drop of a hat, so we tend to forget what a big deal they actually are. Well worth it, true, but all the same it's a big, violent operation on the longest bone in the body. I can't help wondering if it's the shock to the system as well as the pain your poor mother has felt that knocks the stuffing out of a person. So, give her lots of patience and encouragement - and make a rude gesture at that doctor when his back's turned!
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P.S. Also ask and make sure that she'll be getting a script for home care, especially for PT and OT as well as nursing care. The doctor who performed the surgery would generally write that, but if the hospital has what are known as hospitalists (doctors who are directly employed by the hospital), they could write a script as well.
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This is just speculation, but there may be a Medicare coverage issue because your mother is already in the hospital's acute rehab unit, where presumably she is getting PT and being prepared for discharge. The doctor may feel that he should have been notified earlier that you wanted her to go to a separate facility for rehab.

My understanding of coverage is that the patient must be in a hospital for 3 days then transferred to a facility for rehab in order for Medicare to provide coverage. But it's been awhile since we've been in that situation so I don't know if that's still Medicare's position.

If the doctor hasn't explained the situation clearly enough, ask the charge nurse or other unit head on the acute rehab unit. If that doesn't work, find out if the hospital has an ombudsperson, and if not, ask to speak with the hospital administrator.

I think that hospital personnel are the only ones who can really explain to you what their position is and why your mother is being discharged to home, especially if there are issues as to whether or not she's improving, in which case, there would likely be a denial of Medicare to pay for further rehab.
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